Manager of Risk Adjustment

Job Description

Job Description

Manager of Risk Adjustment

Upward Health is an in-home, multidisciplinary medical group providing 24/7 whole-person care. Our clinical team treats physical, behavioral, and social health needs when and where a patient needs help. Everyone on our team from our doctors, nurses, and Care Specialists to our HR, Technology, and Business Services staff are driven by a desire to improve the lives of our patients.

WHY IS THIS ROLE CRITICAL?

This role is critical to advancing the organization's risk adjustment performance by supporting accurate, timely, and sustainable identification of documentation and coding opportunities across the enterprise. The Manager of Risk Adjustment is primarily responsible for managing risk adjustment reporting, data oversight, operational processes, and performance initiatives that strengthen RAF and Medicaid risk score accuracy and support sustainable value-based results.

Reporting to the VP of Quality & Provider Network, this role is responsible for managing risk adjustment operations, data oversight, and performance improvement initiatives. This individual partners closely with Quality, Clinical Operations, Clinical Excellence, Finance, and Provider Network teams to translate data into action, prioritize RAF, risk score, and acuity-focused interventions, and strengthen the processes and systems that support sustainable value-based performance.

KEY RESPONSIBILITIES:

• Manage risk adjustment operations and oversee execution of the annual Risk Adjustment strategy to meet internal and external goals, including reporting, operational execution, and performance monitoring tied to RAF, Medicaid risk score, and acuity outcomes.
• Manage and provide oversight of risk adjustment client data files, including review, prioritization, coordination, and operational use of data outputs to identify opportunities, support intervention planning, and inform risk adjustment decision-making.
• Act as a risk adjustment subject matter expert for RAF, Medicaid risk score operations, performance trends, and related operational processes, including participation in internal and external meetings, health plan client communications, and cross-functional working sessions.
• Oversee the use and maintenance of dashboards, reports, worklists, and performance tools that enable Quality, Clinical Operations, and Provider Network teams to improve RAF and Medicaid risk score performance.
• Translate RAF, Medicaid risk score, and related performance data into clear priorities, operational actions, and recommendations for leadership and partner teams.
• Partner with Clinical Operations, Clinical Excellence, Quality, and Provider Network teams to support risk adjustment performance improvement initiatives, intervention prioritization, and market-specific execution.
• Support the business management of risk adjustment tools, including Navina, and help drive configuration, prioritization logic, workflow design, and adoption across operational teams.
• Track performance goals, monitor outcomes, and provide regular updates and recommendations to leadership to strengthen risk adjustment, RAF, and Medicaid risk score performance across markets and partners.

KNOWLEDGE, SKILLS & ABILITIES:

• Strong analytical and operational mindset with the ability to translate data into clear actions and measurable results.
• Demonstrated ability to manage cross-functional initiatives and influence stakeholders across clinical, operational, and provider-facing teams.
• Excellent communication and relationship-building skills, with the ability to present insights, recommendations, and performance updates to diverse audiences.
• Highly organized and adaptable, with the ability to manage multiple priorities, solve problems proactively, and drive execution in a fast-paced environment.
• Demonstrated success improving processes, driving accountability, and supporting team execution in a fast-paced environment.

QUALIFICATIONS:

• 5+ years of progressive experience in risk adjustment, population health, value-based care, or a closely related function within a payer (preferred) or risk-bearing provider organization preferred.
• Demonstrated success managing or overseeing risk adjustment or value-based performance reporting, client data file workflows, analytics, and improvement initiatives with measurable business impact.
• Bachelor's degree required; advanced degree in healthcare administration, business, public health, or related field preferred.
• Experience working across clinical, operational, and provider-facing teams, with a track record of influencing stakeholders and driving accountability.

Upward Health is proud to be an equal opportunity/affirmative action employer. We are committed to attracting, retaining, and maximizing the performance of a diverse and inclusive workforce. This job description is a general outline of duties performed and is not to be misconstrued as encompassing all duties performed within the position.

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